Surgical Dressings (HCPCS A6010, A6196 & A6197) Quarterly Edit Effectiveness Results of Service Specific Post-Payment Review

The Jurisdiction D, DME MAC, Medical Review Department is conducting a post-payment service specific review of HCPCS codes A6010, A6196 and A6197. The quarterly edit effectiveness results from June 2021 through August 2021 are as follows.

Based on dollars, the overall claim potential improper payment rate is 80% for HCPCS A6010.

Based on dollars, the overall claim potential improper payment rate is 82% for HCPCS A6196.

Based on dollars, the overall claim potential improper payment rate is 89% for HCPCS A6197.

Top Denial Reasons

  • Documentation does not support coverage criteria.
  • Documentation was not received in response to the Post-Payment Notification Letter.
  • Detailed Written Order (DWO) was not received.
  • The claim was submitted with an incorrect modifier.

Educational Resources

Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Surgical Dressings webpage to access coverage documents.

  • National Coverage Determination (NCD)
  • Local Coverage Determination (LCD)
  • Policy Article
  • Documentation letters, forms, and checklists
  • Review tips, tools, and resources
  • Related articles
  • Educational events and tutorials, if applicable

See the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3 for more information on medical record reviews.

 

Last Updated Wed, 20 Oct 2021 16:12:39 +0000